AAFP Tells CMS to Move Slowly on Proposed Episode of Care Groups

May 04, 2017 01:54 pm News Staff

As CMS shifts toward value-based rather than fee-for-service payment, the AAFP recently weighed in on effective ways to develop cost measures that are based on "episode groups," that is, care episode and patient condition groups and codes.

The AAFP responded to the agency's request for comment on episode-based cost measure development under the Medicare Access and CHIP Reauthorization Act (MACRA) with an April 24 letter(5 page PDF) addressed to the Acumen MACRA Episode-Based Cost Measure Team, a group contracted by CMS to help develop new payment policies.

The letter, signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., encouraged CMS to focus initially on "episodes that encapsulate high-cost centers such as hospitals and surgical centers."

"Even though services provided by family physicians are not high-cost when compared to subspecialty services, family physicians have nevertheless been held responsible for total cost of care," the letter stated. "CMS has the opportunity to rectify this imbalance as episode measures are selected that hold those truly responsible for high-cost care more accountable."

The AAFP also said CMS should evaluate the best way to pay for acute care before moving on to the complicated issue of chronic care. The letter pointed out that unlike acute care such as treatment of a broken ankle, which may be simple to track from initial visit to recovery, treatment of chronic conditions is far more difficult to track.

"There is a challenge to develop an episode that encompasses multiple chronic condition specialists," the letter stated. "Often, patients see multiple providers to manage different parts of their chronic disease. However, in family medicine, we treat most, if not all, of these conditions. How can an episode group be constructed fairly to assign cost to one physician caring for three to four chronic conditions vs. three to four physicians caring for the same type of patient?"

The AAFP asserted that cost attribution for patients in specific care episode groups should be made to the physician with the highest Medicare Part B allowable charges, based on paid claims, rather than by which physician sees the patient the most.

And although CMS specifically asked for comment about outpatient care examples that could be the basis of acute care episode groups, the AAFP said it is too early to head in that direction.

"We discourage CMS from prematurely examining outpatient episodes without first learning from inpatient episodes, since that is where the biggest cost savings will be," the Academy wrote.

The AAFP also noted that new episode groups could create confusion if they are designed without considering the outcome of existing bundled payment models based on episodes of care.

"We again urge CMS to beware of creating new measures that they hope will work before the agency has data on how well the existing ones are functioning," the letter stated. "Additionally, CMS should analyze how improved quality affects cost."

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